Professional Documents
Culture Documents
and all botulinum toxin products may spread from the area of injection
to produce symptoms consistent with botulinum toxin effects. These may include asthenia, generalized muscle weakness, diplopia,
ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence, and breathing difculties. These symptoms have been reported hours
to weeks after injection. Swallowing and breathing difculties can be life threatening, and there have been reports of death. The risk
of symptoms is probably greatest in children treated for spasticity but symptoms can also occur in adults treated for spasticity and
other conditions, particularly in those patients who have an underlying condition that would predispose them to these symptoms. In
unapproved uses, including spasticity in children, and in approved indications, cases of spread of effect have been reported at doses
comparable to those used to treat cervical dystonia and at lower doses.
IMPORTANT SAFETY INFORMATION, INCLUDING BOXED WARNING
BOTOX
REIMBURSEMENT SOLUTIONS
Common codes for BOTOX
(onabotulinumtoxinA) indications
Drug Codes
Code Type Code Code Definition
HCPCS II J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT
NDC 00023-1145-01
00023-3921-02
BOTOX
on following pages.
ICD-9-CM codes submitted to the payer must:
Accurately describe the diagnosis for which the patient receives BOTOX
treatment
Represent codes at the highest level of specificity (up to 5-digit codes)
Reflect the contents of any clinical notes and/or chart documentation and be included
in a Letter of Medical Necessity (LOMN) or prior authorization (PA)
BOTOX
on following pages.
Indications
Chronic Migraine
BOTOX
for injection is indicated for the prophylaxis of headaches in adult patients with chronic migraine ( 15 days per month with headache lasting
4 hours a day or longer).
Important Limitations
Safety and effectiveness have not been established for the prophylaxis of episodic migraine (14 headache days or fewer per month) in 7 placebo-
controlled studies.
Upper Limb Spasticity
BOTOX
for injection is indicated for the treatment of upper limb spasticity in adult patients, to decrease the severity
of increased muscle tone in elbow exors (biceps), wrist exors (exor carpi radialis and exor carpi ulnaris),
and nger exors (exor digitorum profundus and exor digitorum sublimis).
Common codes for BOTOX
* 64612
64613
64614
64615
64650
67345
Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for
blepharospasm, hemifacial spasm)
Chemodenervation of muscle(s); neck muscle(s) (eg, for spasmodic torticollis,
spasmodic dysphonia)
Chemodenervation of muscle(s); extremity and/or trunk muscle(s) (eg, for dystonia, cerebral
palsy, multiple sclerosis)
Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal
and accessory nerves, bilateral (eg, for chronic migraine)
Chemodenervation of eccrine glands; both axillae
Chemodenervation of extraocular muscle
Guidance 92265
95873
95874
Needle oculoelectromyography, 1 or more extraocular muscles, 1 or both eyes, with
interpretation and report
Electrical stimulation for guidance in conjunction with chemodenervation (List separately in
addition to code for primary procedure)
Needle electromyography for guidance in conjunction with chemodenervation (List separately
in addition to code for primary procedure)
Modifier -LT -RT
-25
-50
-51
-59
-LT: left side -RT: right side
Significant, separately identifiable evaluation and management service by the same
physician on the same day of a procedure or other service
Bilateral procedure
Multiple procedures
Distinct procedural service
Contact payers to confirm their reporting preferences and determine which procedure code to use. Check payer guidelines regarding the definition of site, coding, and use of modifiers.
*CPT
codes and descriptors are derived from the American Medical Association (AMA) 2013 CPT
manual. These include uses that are outside labeled indications. The procedure codes and
diagnosis codes are for illustrative purposes only, as the practitioner must determine the proper coding for the treatment provided.
This document is for reference only and is being provided in response to inquiries relative to the identification of drug codes, diagnosis codes, and procedure codes. Nothing in this document
is intended to serve as reimbursement advice, a guarantee of coverage, or a guarantee of payment for BOTOX
.
3
Please see additional Important Safety Information for BOTOX
on following page.
Indications (continued)
Important Limitations
Safety and effectiveness of BOTOX
is not intended to
substitute for usual standard of care rehabilitation regimens.
Cervical Dystonia
BOTOX
for palmar
hyperhidrosis and facial hyperhidrosis, respectively. Patients should
be evaluated for potential causes of secondary hyperhidrosis (eg,
hyperthyroidism) to avoid symptomatic treatment of hyperhidrosis
without the diagnosis and/or treatment of the underlying disease.
Safety and effectiveness of BOTOX
cannot be compared to
nor converted into units of any other botulinum toxin products
assessed with any other specic assay method.
Spread of Toxin Effect
See Boxed Warning.
No denitive serious adverse event reports of distant spread of toxin
effect associated with dermatologic use of BOTOX
(onabotulinumtoxinA)
at the labeled dose of 100 Units (for severe primary axillary hyperhidrosis)
have been reported.
No denitive serious adverse event reports of distant spread of toxin
effect associated with BOTOX
.
4
IMPORTANT SAFETY INFORMATION (continued)
WARNINGS AND PRECAUTIONS (continued)
Pulmonary Effects of BOTOX
(onabotulinumtoxinA) in Patients
With Compromised Respiratory Status Treated for Spasticity
Patients with compromised respiratory status treated with BOTOX
for
upper limb spasticity should be monitored closely.
Corneal Exposure and Ulceration in Patients Treated With
BOTOX
for Blepharospasm
Reduced blinking from BOTOX
for Strabismus
During the administration of BOTOX
(3% at
251-360 Units total dose) compared to placebo (1%). In patients with
reduced lung function treated for upper limb spasticity, upper respiratory
tract infections were also reported more frequently as adverse reactions
in patients treated with BOTOX
.
Please see accompanying full Prescribing Information including Boxed Warning and Medication Guide.
2013 Allergan, Inc., Irvine, CA 92612
marks owned by Allergan, Inc. CPT is a registered trademark of the American Medical Association.
www.BOTOXMedical.com/HCP www.BOTOXReimbursementSolutions.com 1-800-44-BOTOX APC54NA13 131492